Circumcision Cuts Rates of Herpes, HPV

Action Points

Explain to interested patients that three major studies have shown that male circumcision protects against the acquisition of HIV.

Note that this study -- undertaken as part of the original three -- now shows that the intervention protects against the acquisition of herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV).

BALTIMORE, March 25 -- New results from a landmark randomized trial show that circumcision protects men against herpes simplex virus type 2 (HSV-2) and human papillomavirus (HPV) infection.

But the intervention had no apparent effect on the risk of acquiring syphilis, according to Thomas Quinn, M.D., of Johns Hopkins University, and colleagues.

Their study -- conducted in Rakai, Uganda -- was one of three that earlier showed circumcision of heterosexual men reduced the risk of acquiring HIV by 50% to 60%, Dr. Quinn and colleagues said in the March 26 issue of the New England Journal of Medicine.

Taken as a whole, they said, the research now indicates the benefits of male circumcision for STD control even as circumcision rates are falling in some of the most at-risk populations.

In an earlier part of the Rakai study, the researchers looked at other effects of circumcision, finding that it also reduced genital ulcer disease. For the latest analysis, they tracked syphilis, HSV-2, and HPV -- three sexually-transmitted infections that are common worldwide.

The Rakai study actually consisted of two parallel but independent trials of circumcision that enrolled 5,534 HIV-negative, uncircumcised male volunteers ages 15 to 49 and assigned them randomly to get immediate circumcision (the intervention group) or after 24 months (the control group).

The researchers tested participants for HIV, HSV-2, and syphilis at baseline and at six, 12, and 24 months. They also performed physical examinations and conducted interviews. As well, a subgroup was tested for HPV infection at baseline and 24 months.

Of the 3,393 volunteers who were negative for HSV-2 at enrollment, 1,684 were assigned to the intervention group and 1,709 to the control group, Dr. Quinn and colleagues said in the journal article.

The researchers found:

At 24 months, the cumulative probability of HSV-2 seroconversion was 7.8% in the intervention group and 10.3% in the control group. The difference amounted to an adjusted hazard ratio in the intervention group of 0.72 (with a 95% confidence interval from 0.56 to 0.92) that was significant at P=0.008.

On the other hand, there was no significant difference in acquisition of syphilis. The adjusted hazard ratio was 1.10, with a 95% confidence interval from 0.75 to 1.65.

In the subgroup tested for HPV, the baseline prevalence of high-risk genotypes in the study arms was similar -- 38.1% in the intervention group and 37.1% in the control group.

At 24 months, however, the prevalence of high-risk HPV genotypes was 18.0% in the intervention group and 27.9% in the control group. That amounted to an adjusted risk ratio of 0.65 (with a 95% confidence interval from 0.46 to 0.90) that was significant at P=0.009.

Dr. Quinn and colleagues noted that the power of the HPV finding is limited by the fact that it was confined to a subgroup of the study population.

Nonetheless, they argued, there is now good evidence that "male circumcision reduces the risk of several sexually-transmitted infections in both sexes.

Indeed, the power of the study -- taken with other evidence -- is such that it should inform public policy, said Matthew Golden, M.D., and Judith Wasserheit, M.D., both of the University of Washington in Seattle.

For a host of sexually-transmitted diseases, "circumcision offers an important prevention opportunity and should be widely available," they said in an accompanying editorial.

They noted that circumcision rates in the U.S. are falling, especially among groups such as blacks and Hispanics, where rates of HIV, herpes, and cervical cancer are "disproportionately high."

"These new data should prompt a major reassessment of the role of male circumcision, not only in HIV prevention but also in the prevention of other sexually-transmitted infections," they said.

They noted that "The American Academy of Pediatrics, which previously concluded that evidence was insufficient to recommend routine neonatal circumcision, is reviewing its position in collaboration with other professional organizations."

The study was supported by the NIH, the Bill and Melinda Gates Foundation, the Fogarty International Center, and the National Institute of Allergy and Infectious Diseases.

Dr. Quinn reported no conflicts. Dr. Golden reported financial links with Pfizer and Dr. Wasserheit reported research support from the Bill and Melinda Gates Foundation.

Reviewed by Zalman S. Agus, MD Emeritus Professor University of Pennsylvania School of Medicine

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.